Wiki E/M auditing

[metzger130]

I was asked to audit a few E/M's for one of the physicians we bill for. I have a couple of questions on ROS/Organ systems. The physician is a cancer doctor. Like all doctors the doctor goes over their Height, weight, and blood pressure. I am thinking this would count when trying to figure out the level, am I correct in this or is this just considered something you do and it doesn't count? In one example the patient has breast cancer. In the physical exam they are checking lymph nodes (nothing wrong there), ENT, no lesions found. Lungs, a little weazing due to allergies, Cardio: nothing irregular found. Abdomin: no masses found. Breasts: talks about how they look and if any abnormalities. This is basically a summary, not exactly what the doctor said, I don't want to be to specific on here, but you get the idea. For those areas that are not the breast area, but they are looking and saying there is no abnormalities (lumps, masses, etc) do you count those towards the level or becasue there is nothing there and it is not part of the breast you woldn't count? I would think you would count it since it is cancer and cancer spreads and you would want the doctor to check all those areas to make sure nothing new has come. There is a little debate about whether breasts go into the GU (since it is a reproduction organ in females) or if it goes in integumentary.

Thanks,
Rob

 

[Pam Warren]

I just want to clarify: you asked about ROS, but it looks like your questions relate to the exam. In that case, regarding your question with Height/weight/BP; this would absolutely count for the exam for an oncologist. For example, unexplained additional weight loss, or changes in BP might indicate side effects of treatment or progression of disease. If you count BA and OS as in the 1995 guidelines, you'd count breasts under the Chest/Breast BA. Other common areas that might be checked for lumps/masses might fall under lymph or integumentary, depending on where and why the doc is palpating, and I would go ahead and count them if they're in a different OS/BA than Chest/Breast/Axillae.

Here are the BAs we consider: Head/Face, Neck, Abdomen, Chest/Breast/axillae, Genital/Groin/Buttocks, Back (including spine), Extremities.

The OS are: Constitutional, Eyes, Ears, Cardiovascular, Respiratory, GI, GU, Musculo, Skin, Neuro, Psych, Hem/Lymph/Immuno.

This is directly from the 3/31/2010 of the NHIC (contractor for New England) E&M Coding Worksheet, which is pretty consistent with other carriers. Even negative findings on the exam are counted, because the provider is using that information to assess the patient's current condition. I think it's important to be able to figure out if the provider is reporting back what the patient is telling him (which would count as your ROS) or if he actually did an hands-on exam. From what you've indicated, it looks like he actually did an exam.

 

[metzger130]

Thanks for that information. Yes it was an exam that he did all those itmes. I was thinking you would count them but I wanted to check with others before I would say it for sure. I also know that some insurance companies are more a pain then others when it comes to what they "think" should be counted and such. I obviously don't anticipate an audit anytime soon but just wanted to double check.